Jesse H. Wright, MD, PhD

As psychiatric practice moves increasingly to brief treatment sessions, fewer psychiatric office visits are being devoted to providing traditional-length psychotherapy.

 Yet, there are many reasons to consider using psychotherapeutic methods in the briefer sessions that dominate contemporary clinical practice.

 A primary reason is the lack of full symptom control from psychopharmacological treatment for a large number of patients.

There is evidence that the combination of medication and psychotherapy improves outcomes for many psychiatric illnesses, including depression, bipolar disorder, and schizophrenia. Among the several forms of psychotherapy that might be considered, cognitive-behavioral therapy (CBT) is the most extensively studied. A meta-analysis of combined treatment for depression has shown that using medication plus CBT has an advantage over monotherapy.

 Several trials have also shown superiority for adding CBT to antipsychotic medication for schizophrenia.

Other reasons for psychiatrists to use psychotherapy, even in relatively brief sessions, when they are also providing medication management, include:

• Findings that the majority of patients come to treatment with psychosocial issues and stresses that lead them to prefer psychotherapeutic interventions over a treatment plan that uses medication management alone

• The value of conceptualizing and treating psychiatric illnesses with a biopsychosocial treatment model

• Possible advantages, such as cost-effectiveness, of delivering pharmacotherapy and psychotherapy as an integrated method

• Evidence that psychotherapy can complement the effects of medication via biologically mediated mechanisms

Recognizing the importance of psychotherapy skills in psychiatric practice, the Accreditation Counsel for Graduate Medical Education psychiatry residency program requirements (

http://acgme.org/acWebsite/RRC_400/400_prIndex.asp

) mandate that residents must achieve competency in cognitive-behavioral, psychodynamic, and supportive therapy approaches. But what happens when residents enter practice and must face the reality of demands to treat patients in efficient ways that de-emphasize the use of longer psychotherapeutic interventions? And how can practicing psychiatrists respond to the challenge of incorporating psychotherapeutic methods into brief sessions when the primary focus may be on providing effective pharmacotherapy?

Surprisingly little has been written about specific methods for using psychotherapy in brief sessions. Our literature review found a limited number of citations that described the use of CBT in brief sessions.

Clearly more research is needed, but sufficient clinical experience has been accumulated to develop a guide for psychiatrists who wish to use CBT principles and techniques in their brief treatment sessions.

CBT is an ideal psychotherapy method to consider for use in brief sessions with pharmacotherapy because of the following:

• It is fully compatible with an integrated biopsychosocial treatment approach

• Many psychotherapeutic interventions can be delivered within a short time frame

• The structured techniques of CBT can help clinicians and patients make the best use of available time

• Psychoeducation is a central element of therapy

• The CBT skills that are taught in brief sessions can be practiced as self-help exercises during regular homework assignments

High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide,

17 includes video illustrations of a variety of CBT applications that last from about 5 to 15 minutes. Examples of methods that can be delivered in a short time frame are listed in 

To illustrate the use of CBT in brief sessions, the applications for 3 common psychiatric disorders are described below.


Exposure therapy in brief sessions along with an SSRI were used to treat a patient with obsessive-compulsive disorder (OCD) who had counting rituals. After the patient was educated about the CBT model for OCD, she agreed to a plan of setting targets for exposure therapy and carrying out the assignments between sessions. During 15 brief sessions that lasted about 20 minutes each, the psychiatrist checked for effects of the medication, reviewed the patient’s homework, assisted her with setting targets for progressing with exposure therapy, and helped her troubleshoot any problems with completing exposure tasks.

CHECKPOINTS 
? The majority of patients who come for treatment of psychosocial issues and stresses prefer psychotherapeutic interventions over a treatment plan that uses medication management alone.

? Although brief cognitive-behavioral therapy (CBT) sessions can provide a useful treatment alternative, longer sessions are recommended when patients have symptoms that require intensive psychotherapy, psychosocial problems that need to be addressed in 50-minute sessions, a desire to have intensive therapy in long sessions, or a failed response to combined brief CBT and medication.


The psychiatrist occasionally used cognitive restructuring with Socratic questioning and thought recording to help her reduce irrational fears of what might happen if she didn’t complete the rituals. The patient reached her goal of reducing the time spent in counting rituals to 5% of the baseline level. At that point, she concluded that the very small amount of counting that remained had little or no effect on her life.


The patient had had bipolar disorder for many years and continued to have mood swings at least 4 times a year despite extensive treatment with combinations of mood stabilizers and second-generation antipsychotics. After his previous psychiatrist retired, the patient began treatment with another psychiatrist who suggested a reassessment of the pharmacotherapy regimen in addition to using CBT in brief sessions. The initial treatment plan included monthly visits, with the option to meet more frequently if needed.

In an early intervention, the new psychiatrist elicited the patient’s cognitions about having bipolar disorder and taking medication. As he revealed cognitions such as “I don’t think I really have bipolar disorder,” “I hate taking medication,” “Sometimes, I think I’d be better off with no medication,” the psychiatrist used a collaborative CBT approach to examine the evidence for these beliefs. Psychoeducation and motivational interviewing were used to help the patient fully accept the diagnosis (for which there was strong supportive evidence), to weigh the advantages and disadvantages of pharmacotherapy, and to develop a mutually acceptable plan for revising his medication regimen to attempt to gain better control over the mood swings. Behavioral methods were also used to enhance adherence.

As treatment proceeded, brief sessions were enriched by use of CBT methods to improve the patient’s sleep patterns; to teach him to write coping cards (for reducing irritability in interpersonal situations); and to help him identify cognitive errors, such as magnifying positive attributes and minimizing risks that had commonly occurred when he became manic. Treatment goals included improving adherence and gaining CBT skills that might reduce the risk of relapse.


Despite intensive treatment with antipsychotic medication, the patient continued to have auditory hallucinations that harassed and condemned her. She was receiving high-dose clozapine and reported full adherence with the medication regimen. Her psychiatrist monitored the treatment with clozapine carefully but also used CBT methods that have been adapted for schizophrenia to try to reduce the negative impact of the residual symptoms.

 These methods included normalizing the experience of hallucinations, examining the evidence for the validity of the voice content (eg, “You’re stupid,” “You deserve to die,” “You should have never been born”), coaching the patient on useful behaviors to lower the intensity and the influence of the voices, and writing out a coping card for managing the voices. Although the patient continued to experience hallucinations, the CBT component of treatment appeared to significantly reduce the distress associated with psychotic symptoms and improve her ability to function in everyday life.


In our clinical practices, some patients are treated with brief sessions only, some have longer sessions for part or all of their treatment, still others are treated in collaboration with nonphysician therapists who provide more extensive psychotherapy.13 The indications for selecting these different formats for combined CBT and medication have not been studied systematically.

Although brief sessions can provide a useful treatment alternative for some patients (

), we recommend longer sessions when patients have symptoms that require intensive psychotherapy, psychosocial problems that need to be addressed in 50-minute sessions, a desire to have intensive therapy in long sessions, or a failure to respond to combined brief CBT and medication.

As psychiatric practice continues to evolve, the biological understanding and treatment of mental disorders is likely to gain more importance. However, there will still be a need for psychiatrists who can combine psychotherapy with biological treatments in the service of helping patients reduce symptoms and cope better with illness. CBT appears to offer potential for effective use in brief sessions and deserves further development and study as a therapeutic tool for combined pharmacotherapy and psychotherapy. We look forward to further refining and testing this approach.

Dr Wright receives royalties or other payments from the sale of software for computer-assisted CBT, a treatment method discussed in this article. Drs Wright and Thase receive royalty payments from American Psychiatric Publishing, Inc, for sales of books that are referenced here. Although medications that may be used in combination with CBT are not the focus of this article, Dr Thase is a consultant to, and has received research funding and speaker’s honoraria from, the manufacturers of a number of those medications. Drs Wright and Thase receive grant support from the National Institute of Mental Health (R01 MH082762) for research on computer-assisted cognitive-behavior therapy for depression.

Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. 

Gabbard GO. Empirical evidence and psychotherapy: a growing scientific base. 

Clemens NA, Bebchuk W, Beitman BD, et al. Disputing psychiatry’s redefinition. 

Gabbard GO, Kay J. The fate of integrated treatment: whatever happened to the biopsychosocial psychiatrist? 

Gabbard GO. Psychotherapy in psychiatry. 

Dewan M. Are psychiatrists cost-effective? An analysis of integrated versus split treatment. 

Friedman ES, Wright JH, Jarrett RB, et al. Combining cognitive therapy and medication for mood disorders. 

Tarrier N, Yusupoff L, Kinney C, et al. Randomized controlled trial of intensive cognitive behaviour therapy for patients with chronic schizophrenia. 

Sensky T, Turkington D, Kingdon D, et al. A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. 

Articles

There is evidence that the combination of medication and psychotherapy improves outcomes for many psychiatric illnesses. Among the several forms of psychotherapy that might be considered, cognitive-behavioral therapy (CBT) is the most extensively studied.

Combining High-Yield CBT Methods and Pharmacotherapy in Brief Sessions

The prospect of using computers to deliver psychotherapy has been intriguing a number of investigators who have been studying innovative methods of bringing technology into clinical practice. The most dramatic form of computer-assisted therapy (CAT) is virtual reality exposure therapy in which patients are immersed in a virtual environment to help extinguish fears of flying, heights, social situations, or other anxiety-provoking situations. Other commonly used CAT methods are multimedia applications that use video, audio, and interactive exercises to convey therapy concepts and to build coping skills. Handheld devices encourage patients to monitor themselves and to use behavioral methods to manage symptoms. CAT can:

• Reduce cost and improve access to empirically tested psychotherapies.
• Reduce the need for therapists to perform repetitive procedures, such as psychoeducation or rehearsing basic CBT procedures. 
• Enhance the therapy experience by providing engaging or unique learning opportunities.


Other strengths include giving constructive feedback; promoting use of CBT homework; and recording, analyzing, and reporting data.

CAT can be defined as psychotherapy that uses a computer program to deliver a significant part of the therapy content or to assist the therapist. Clinician involvement usually includes at least screening, supervision, and support of computer program use and may involve an integrated human-computer team approach to treatment.

 The amount of therapist involvement in CAT varies considerably in different studies but is substantially less than that in standard therapy. For example, programs that have shown efficacy for depression and panic disorder have reduced the therapist contribution to 4 hours or less for the entire treatment course.

Several self-help computer programs that do not use clinician monitoring or involvement are available on the Internet. Although these programs may teach self-help concepts, a recent meta-analysis found that lack of support from a human therapist was associated with far less robust changes in symptoms than was therapy that integrated the work of the clinician and the computer.

Completion rates of program content are usually quite low when a clinician is not involved. For example, a study of the use of Mood Gym, an Australian Web site, found that the vast majority of users appeared to be browsers who only viewed a small portion of the available content.

 In contrast, an Internet-delivered program for posttraumatic stress disorder (PTSD) that was directed and supported by clinicians was completed by 70% of the participants.


Early in the development of CAT, attempts were made to construct programs that used “natural language,” in which the computer would try to engage users with dialogue that was similar to that used in therapeutic communication between patient and clinician in nondirective or supportive psychotherapy.

 However, these programs were unable to duplicate therapeutic interviews accurately or reliably. Thus, contemporary CAT applications use a different approach-they present learning and skill-building exercises that can help patients better understand and manage symptoms.

Virtual reality applications have been found to be effective for a variety of anxiety disorders.

 studied programs for patients with PTSD, fear of flying, and acrophobia. Difede and associates

 recently showed that a program that creates a virtual environment of the World Trade Center attacks on September 11, 2001, was very helpful in reducing symptoms of PTSD. In these studies and others, virtual reality allows the therapist to implement graded exposure treatment in the office while simulating an in vivo experience of the anxiety-provoking situation. The clinician controls the pacing and intensity of the exposure therapy and uses CBT to help patients break patterns of avoidance and extinguish their fears.

Multimedia programs that have been developed for depression and anxiety are another potentially useful application for CAT. As with virtual reality therapy, these programs typically use a CBT approach, in which patients learn to revise dysfunctional thinking and reverse maladaptive behaviors. Examples of multimedia programs that have been tested for depression include the software Good Days Ahead: The Multimedia Program for Cognitive Therapy and Beating the Blues.

In a study of Good Days Ahead in drug-free patients with major depression, there were no differences in symptom relief in patients treated with computer-assisted CBT and in those treated with standard CBT, even though therapist contact time was reduced by almost half.

 The computer program appeared to offer advantages over standard CBT in lowering dysfunctional attitudes and enhancing learning of CBT concepts. The Beating the Blues program led to improved outcomes in both depression and anxiety in primary care patients who had the computer training in addition to treatment as usual.

 Fear Fighter, another multimedia program developed in the United Kingdom, has delivered results similar to those of standard CBT for anxiety disorders despite use of modest amounts of clinician time.

Handheld computers have also been used as treatment adjuncts. Newman and associates

 have used this type of CAT to treat panic disorder, and Gruber and coworkers

 have used it to provide CBT for social phobia. Both groups demonstrated that a handheld computer can promote self-monitoring and use of standard CBT methods for anxiety disorders, thus reducing the requirements for therapist time. For example, Newman and associates

 found that a shortened form of computer-assisted CBT for panic disorder (4 sessions with a therapist) was slightly less effective than a full course of CBT (12 sessions), but there were no significant differences between the 2 forms of therapy at follow-up.


Although currently available, CAT programs have been effective in research studies; they have limitations in clinical practice. CAT programs do not perform full psychiatric assessments, make diagnoses, or develop comprehensive treatment plans; nor do they screen for and manage impulsivity or other potentially dangerous behavior, such as suicidality. And, of course, they cannot display the empathic concern, wisdom, flexibility, and creativity of human therapists. Thus, in clinical applications, CAT programs appear to be best suited as components of an overall treatment strategy that is prescribed and guided by a professional.

CAT is just beginning to take hold in psychiatric practice. Although a vigorous effort is under way to produce and test programs for psychiatric treatment, and the use of computers in society is steadily increasing, most clinicians are either unfamiliar with CAT or have not yet tried to use these programs to augment traditional therapy. The time may be near when clinicians who want to use technology in psychotherapy will have access to useful and effective programs that can enhance learning, make treatment more efficient, and bring a valuable new dimension to the psychotherapeutic process.

Therapists of the future may be able to conduct their daily work with a variety of empirically tested computer tools. These adjuncts could be completed before or after a session, either in waiting rooms or at home, or even in specially designed therapy suites that provide advanced technology (such as virtual reality and fully realized multimedia treatment programs). Further development of port­able devices that have better function­ality and connectivity, that offer more realistic and engaging programming, and that weave together the human and technological components of treatment could provide a myriad of opportunities for realizing the promise of the computer as a therapeutic “assistant.”

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The prospect of using computers to deliver psychotherapy has been intriguing a number of investigators who have been studying innovative methods of bringing technology into clinical practice.

Jesse H. Wright, MD, PhD

Articles

Combining High-Yield CBT Methods and Pharmacotherapy in Brief Sessions

Computer-Assisted Psychotherapy